AUTUMN 2016 ISSUE FIFTEEN

Kellie Payne

Learning and Research Manager Campaign to End Loneliness

Matthew Prina

Lecturer in Ageing and Mental Health King’s College London

Nicole Valtorta

Research Fellow in Public Health University of York

contributors:

opening thespiritual gate

PAGE 9

MENTALHEALTH

loneliness & depression

can video-callsprevent

loneliness?

PAGE 20

cochranereviewPAGE 18

Those that provide care,must careTracey Robbins talks about the work of The Big Lunch; anEden Project aiming to bring together communities. Somehelpful suggestions of what people can do to combatloneliness are also provided.

Junior doctors’ perspectiveon lonelinessDr. Poppy Mackay and Dr. Grace Baxter from the OlderAdult Liaison Psychiatry Team at Chelsea and WestminsterHospitals discuss the important role that Junior Doctors’ canplay in helping to tackle loneliness.

Welcome...

innov-age magazine issue fifteen autumn 20162

This is our 15th issue andwe thank you for all ofthe excellent feedback wehave received from you todate. We are aiming tocontinually develop thepublication and wouldwelcome your thoughts inhelping shape furtherissues. If you have time,please fill in the attachedquestionnaire, orcomplete the onlineversion (see page 12). Inthe meantime, wewelcome you to this issuefocussing on mentalhealth – loneliness anddepression.

As we get older, circumstancessuch as retirement,bereavement, lack ofcompanionship and poor healthcan increase feelings ofloneliness. Chronic lonelinesscan cause real distress and have

We also hear of the importanceof addressing people’s spiritualneeds, an award winninginnovation that is tacklingmalnutrition and the work ofJohnnie Johnson Housing Trustto help older people liveindependently for longer.

Finally, our resident contributorTracey Howe provides anoverview of the literaturesurrounding depression in olderpeople as well as an introductionto the newly establishedCochrane Global Ageing.

I hope you feel inspired afterreading this issue to get in touchwith family, friends orneighbours. For me, the thoughtthat many older people regardtelevision as their main form ofcompany is heart-breaking.Everyone should deserve to feellike they have somebody to turnto – even just a good chat andcup of tea can break themonotony of the day.

a serious impact on bothphysical and mental health. Ithas been found to significantlyincrease the risk of having astroke, developing coronaryartery disease, Alzheimer’s andpremature death. It is also amajor cause of depression.Evidently, social contact iscrucial for our wellbeing.

Leading this issue, TraceyRobbins highlights the work ofthe Eden Project, trying to bringcommunities together andtherefore increase people’ssocial networks. Kellie Paynefrom the Campaign to EndLoneliness discusses their newreport that aims to helpcommissioners identify people atrisk of suffering from loneliness,in order to implement services toalleviate this.

We also learn of the role thatJunior Doctors can play inhelping reduce loneliness andcurrent research into whethervideo-calls can improve theoverall quality and quantity ofpeoples’ contact. Matthew Prinaintroduces an EU-funded projectcalled ATHLOS and its findingsrelating to depression andhealthy-ageing. Kate Bennettemphasises the beneficialeffects of exercise on mentalwellbeing and suggests ways toget active, whilst researchers atthe University of York discussthe implications of what weknow about loneliness in olderage for prevention strategies.

Editorial foreword

Jackie Oldham

Honorary Director, Edward Centre for HealthcareManagement Research

autumn 2016 issue fifteen innov-age magazine 3

Edward Centre for HealthcareManagement Research,Citylabs,Nelson Street,Manchester,M13 9NQ

www.innov-age.orginfo@innov-age.org

0161 276 4473

If you would like to subscribe forfree, contribute or have any otherenquiries, please contact the teamor visit our website. We lookforward to hearing from you.

Editorial Team Jackie Oldham, Louisa Gerrard,Richard Deed, Peter Bullock.

ContributorsJackie Oldham, Tracey Robbins,Kellie Payne, Poppy Mackay, Grace Baxter, Karen Groves, Kate Bennett, Patricia Grierson,Nicole Valtorta, Simon Gilbody,Sonam Zamir, Matthew Prina,Kirstine Farrer, Tracey Howe.

Innov-age® is the official magazine of the EdwardCentre for Healthcare Management Research, part of the Edward Healthcare group of companies.

Published in the UK by Edward Centre for HealthcareManagement Research, part of the Edward Healthcaregroup of companies. Innov-age is produced inassociation with TRUSTECH, MIMIT and MAHSC.

© 2016 Edward Centre for Healthcare ManagementResearch, part of the Edward Healthcare group of companies.

The contents of this publication are protected bycopyright. All rights reserved. No part of thispublication may be reproduced, stored in anyretrieval system or transmitted in any way form or by any means without the written permission of thepublisher. The views expressed in this publication arenot necessarily those of the publisher or editorialteam. While the publisher and editorial team havetaken every care with regard to accuracy of contentthey cannot be held responsible for any errors oromissions contained therein.

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ISSN 2052-5753 (Print)

Contents

page

Insight – Those that provide care, must care 4Finding the loneliest in our communities6Junior Doctors’ perspective on loneliness8Opening the spiritual gate9Get up and go for it!10News…12Living longer, living better14Loneliness in later life: opportunities andchallenges for intervention 16Cochrane Corner – Review18Can video-calls help prevent loneliness for care home residents?20Depression and healthy ageing: current state of the evidence21PaperWeight Armband22Spotlight on…23

Insight

innov-age magazine issue fifteen autumn 20164

Those that provide care, must care

Loneliness is the mismatch between the relationshipspeople have and those that they want. It is their internaltrigger telling them to seek company, just as thirst tells them to drink and hunger tells them to eat (Robbins, 2014).

In combatting this, Dr Keming Yang (2015), SeniorLecturer in Sociology at Durham University, argues thatloneliness is a social problem and therefore needs a socialsolution.

One could go a step further, and say that;Loneliness is a human condition and needs ahuman response.

Loneliness affects everyone, but many older and youngerpeople experience overwhelming feelings of loneliness.

So what is loneliness?

Loneliness describes the pain of being alone (whereassolitude describes the joy of being alone). Somebody canbe surrounded by lots of people and still feel lonely.

Through her work with the Joseph Rowntree Foundation(JRF), Tracey learnt that loneliness can affect anyone,regardless of age. In fact, it affects 15–25 year olds thesame as those over the age of 65. It affects people’shealth and their communities. This makes place-basedapproaches to reducing loneliness crucial, connectingpeople to each other in the areas where they live.

Through the community led approaches to povertyprogramme (JRF), Tracey gained a greater understandingof, and insight into, the importance of intergroup work increating empathy for others (Fell and Hewstone, 2015).

In her current role for the Eden Project (delivering its UKwide community outreach programme and The BigLunch), Tracey and her colleagues aim to connect peoplewith each other and the living world, exploring how theycan work towards a better future. They bring togetherpeople of all ages and backgrounds wherever they live.

Over the past six years while Tracey has been working onloneliness, disconnection and loss, she has lost her

mother, had her grandchildren move away, colleaguesleave and job roles change. But often there is very littleroom in life to consider the impact of lonelinesspersonally, let alone for those as professionals.

Those in work find the environment pressured, limited,and functional. They lack time to build new relationshipsand friendships, often having long distances to travel,working long hours or juggling numerous jobs – meaningthere is often no time to socialise or engage with theirneighbours or their communities.

For those who no longer work, no longer have a ‘job’ todo, including volunteering, caring for others, raising afamily etc. there is a sense of worthlessness thataccompanies loneliness. This increases the longing for areturn to the world or life that they once had, for theirconnections, structure, purpose and for their sense ofidentity. Often the people being cared for are longing fortheir families, friends and communities of times past.Many people will have come across those whose sense ofloss and loneliness has left them unable to engage in, orforgotten by, previous networks.

To add to this sense of loneliness and lack of worth, olderpeople often find themselves grouped together: inresidential care, groups, activities and clubs for peersupport and solace. However, this common remedy forsocial support may not be as soothing as is hoped andmay even have a negative impact. This is because theirpeers are also likely to be experiencing the same sense ofloss, lack of identity, low self-esteem and loneliness whichcan reinforce an individual’s sense of worthlessness.

A potential way to reduce loneliness is to think about‘intergroup’ contact. All too often like with like are puttogether, but it ought to be the lonely and not lonely,socially connected and socially isolated, employed andunemployed that are brought together. This will not onlydisrupt the negative and judgemental stereotypes thatprevail about getting older or being younger, but willimprove understanding and attitudes. It will promotepositive emotions such as empathy and it will help peopleto reconnect as humans.

Tracey Robbins has recently been appointed as the Big Lunch Community DeliveryManager. She previously worked as Policy and Research Manager on the NeighbourhoodApproaches to Loneliness programme at the Joseph Rowntree Foundation. Tracey’scareer has focussed on asset based community development approaches, health,wellbeing and social care within the voluntary and community sector for 20 years. Traceyuses action research and participatory techniques to work directly with individuals andgroups to bring about change, develop opportunities and redress imbalances.

autumn 2016 issue fifteen innov-age magazine 5

The long term ramifications of the devaluing of so manylives is sobering and heart breaking for both the youngand the old and those in between.

Lonely people are often excluded from the opportunitiesmany people take for granted – especially those in care.They don’t have access to new opportunities, to meetingnew and different people in ordinary everyday situations,and yet it is from these that people develop newrelationships, experiences, insights, interests, hobbies andhopefully new friendships. For Tracey, it can be as simpleas chatting to people on the train, trying yoga becauseworkmates have inspired her to give it a go, or thehappenstance of recently meeting her old colleague in avillage hall, in a village where neither of them lived. Shehadn’t seen her for six years – they are meeting up forcoffee next week.

These are simple, ordinary, everyday things that matter toeveryone.

Marie Greenhalgh, Big Lunch Extras participant,recognised the lack of opportunity for older people and isnow running a project to address loneliness and isolationfor older people living in her community near Manchester.

Marie’s inspiration came from working in a similar paidposition near to where she lives.

‘I was getting referrals to my project for lonely peoplefrom Wythenshawe, my home town, but I was unable toaccept them because the funding didn’t allow it.’

Feeling increasingly uncomfortable about this, Marie tookthe brave decision to leave her job and set up a project inher neighbourhood.

Initially she coordinated and trained volunteers to visitolder people in their homes, befriending them andsupporting them with everyday tasks. Marie was keen todo more though, and says, ‘I was at a bit of a crossroads,feeling overwhelmed by what I had taken on. However,after joining the Big Lunch Extras programme andattending the camp at the Eden Project, I went back with

renewed vigour and got a community coffee morning offthe ground in my local pub.’

Marie says the pub ‘was a place for younger people togather and did not engage and attract volunteers andelderly people’. However, now they hold weekly coffeemornings for isolated elderly people and their families.This is first and foremost a chance to come together andsocialise, but Marie also arranges easy access to localservices in an informal setting. A hair stylist, optician,solicitor and a pharmacist are regularly available. Aspeople’s confidence grows, more people are arranging tomeet independently and plan outings.

What can people do about loneliness?

• Make every contact and conversation count • Know how to ask the next question—and ask it• Be pre-emptive and proactive • Look out for loneliness • Look after the health and wellbeing of themself, their

colleagues, and their neighbourhood • Ensure groups and activities have welcomers and are

open to all • Look out for opportunities to meet people, and

cultivate new friendships and social interactions • Smile and say hello, even when it’s hard• Create and safeguard their personal convoy of

friendships and social networks • Talk about loneliness • Don’t give up, get out • Give the gift of time, give someone a little extra time

Also be aware that:

• Practical, flexible, low-level informal support is oftenmost effective

• Lonely people often expect rejection, so focus on thepositive. Expect the best.

Tracey Robbins ,

Community Programme Delivery Manager

The Big Lunch, Eden Project

References:

Fell, B. and Hewstone, M. (2015). Psychological perspectives on poverty. [online].Available at: https://www.jrf.org.uk/report/psychological-perspectives-poverty

Robbins, T. (2014). Let’s talk about loneliness. [pdf] Joseph Rowntree Foundation

Yang, K. (2015). Response. In: Church Urban Fund, Creating conversations: ExploringCommunity-Based Responses to Poverty. [online]. Available at:https://www.cuf.org.uk/2016-publications (p.11)

For more information on current research and bestpractice, the Campaign to End Loneliness(campaigntoendloneliness.org) is recommended.

Those that provide care, must care:

‘The business of business isrelationships. The business of life ishuman connection.’

Robin S. Sharma

innov-age magazine issue fifteen autumn 20166

Research

Finding the Loneliest inour Communities Dr Kellie Payne graduated in 2015 with a PhD in Cultural Geography from the Open University. She looksafter the Campaign’s Learning Network which is made up of over 1000 member organisations who workwith older people on the issue of loneliness. Kellie also manages the Research Hub which comprises 100 academics working in the area of loneliness research. Prior to her PhD, Kellie worked in ResearchCommunications at HGCA (Agriculture & Horticulture Development Board, Cereals and Oilseeds). Kellie isoriginally from Chicago, Illinois and has been in London since doing her MSc at the London School ofEconomics and Political Science (LSE) in 2004.

Everyone has experienced the hurt and pain ofloneliness at one point in their lives. It can be anawful, debilitating feeling that makes us feel trappedand unable to cope with life. For most this is atemporary feeling caused by a change in one’scircumstances in life. For others though, this is along-term and chronic condition.

On average 10% of the population of people aged 65and over say that they are lonely often or always.This equates to over one million older people in theUK who suffer from chronic loneliness. Because ofthis, the public and political attention on lonelinesshas sharpened significantly as the social, economicand moral case for tackling this issue grows inawareness, evidence and support.

However, while it is known that there are somemillion older people experiencing chronic loneliness,finding them, in order to help them, can be difficult.When the Campaign to End Loneliness teamsurveyed a collection of over 1000 service providers,they were consistently told it would be difficult tohelp identify lonely older people.

To address this problem, the Campaign team haspublished two reports. The first, a research reportexamining methods of identification, is called ‘HiddenCitizens: How Can We Identify the Most LonelyAdults?’1 and was published in 2015. In June of thisyear, the Campaign also published new guidanceentitled ‘Missing Million: In Search of the Loneliest inOur Communities’.

The Missing Million report (hereafter referred to as‘the report’) aims to help commissioners and serviceproviders develop methods to help them identify olderpeople that are experiencing, or are at risk ofexperiencing loneliness. The report also includes casestudies which illustrate the methods identified.

The first section of the report, entitled ‘IdentifyingLoneliness’, explains different methods of identifyingthe lonely. It focuses on two types of approaches. Thefirst is a top-down approach which seeks to discoverwhat data is available to help locate lonely individualsand to find geographical areas that are more likely tohouse older people at risk of becoming lonely. Thesecond is a bottom-up approach that looks at waysthat local, hidden intelligence might be used.

Loneliness Heat Maps

Crucial to this first approach is the use of data to helpidentify those at risk of being lonely. The reportfeatures three different means of using different datasets to do so. One of the most promising of theseapproaches is using a tool developed by Age UK.They developed ‘loneliness heat maps’ working withthe Office of National Statistics (ONS) to show thelevels of risk of loneliness in a given area. Byanalysing English Longitudinal Study on Ageing(ELSA) data, they isolated the six risk factorsassociated with feeling lonely.

Of these factors, three were measured in the Census(marital status, self-reported health status, and ageand household size) and could be found in the ONS

autumn 2016 issue fifteen innov-age magazine 7

Dr Kellie PayneLearning and Research Manager

Campaign to End Loneliness

data set. A model was run on the 2011 Census datawhich enabled the team to produce maps of the datafor individual localities. Risk of loneliness could bemapped at the neighbourhood, ward and street levelusing the tool that was developed.

These maps can help commissioners and serviceproviders determine which parts of an area have ahigher risk of loneliness among the older population.It will show which areas have a higher concentrationof loneliness and allow service providers to determinewhere to best target their resources. It should benoted that the maps do not take account of variationswithin individual and community resilience, which willaffect how an individual person and their surroundingcommunity might react to the risk of loneliness. It is,however, a great indicative tool to show where therisk lies, enabling people to target resources.

Age UK have developed a series of pilot projectswhich are using the heat maps to help them identifywhich parts of their local areas they should target. Forexample, Age UK Wirral has a project entitled‘Friends in Action’ and when they mapped their localarea, they noticed that there appeared to be a highpercentage of possible loneliness in a specific area.The team identified that there was a lack of socialactivities being programmed in this area and indiscovering the high risk levels, they decided todevelop more provision in that area. They set up anew monthly coffee morning which is going to beextended to a lunch club. The participants in theprogramme have said that this provision of serviceallowed them to build their social networks and in turnhelped reduce their loneliness.

Exeter Data System

Another data set that can be applied to loneliness isthe Exeter System which is a database of all patientsregistered with an NHS GP in England and Wales andis hosted by National Health Applications andInfrastructure Services (NHAIS). In order to protectpatient confidentiality, access to the data is restricted.However, pioneering data sharing agreements havebeen developed which enable the data to be used.

The best example is a project entitled SpringboardCheshire in which an agreement was made betweenthe NHS and a coalition between Cheshire Fire andRescue Service (CFRS) and Age UK Cheshire. Usingtheir access to the Exeter System, Springboard

Cheshire supplemented information with other datafrom open sources (for example; assisted bin delivery,home oxygen therapy, and fuel poverty) whichenabled households to be ranked and prioritisedaccording to certain risks. This combined data is oftenreferred to as ‘Open Exeter’. There is an overlapbetween these risk factors and the risk of having adomestic fire. Using the list created, the CFRScarried out home visits to vulnerable people andbecause they were partnered with Age UK Cheshire,they were able to signpost these people to furthersupport. The success of the Cheshire scheme has ledto a wider collaboration between the NHS and theFire and Rescue Service.

Co-production and conversations

In addition to these examples of using data sets andmapping, the report also includes methods which arecommunity driven and a project entitled ‘ConnectedCommunities’. Another aspect explored is thepossibility of creating partnerships. Also, the idea ofcreating programmes using the method of co-production which ensures that users work togetherwith service providers to create service provision.

The final section of the report introduces ways to talkto someone who might be lonely and engage them ina meaningful and helpful conversation. It stressesthat when engaging a possibly lonely individual, youshould ensure you use the skills and qualities ofempathy, openness, warmth and respect to facilitatea conversation about loneliness and the psychologicaldistress it causes. A conversation should be problemsolving and should enable signposting to availableresources in order to help the person.

Combined, the new report sets out interesting anduseful ways people can go about using data to findthose at risk of loneliness, gives examples of themethods used and ways to start a conversation oncethey are found.

The report can be found here:http://www.campaigntoendloneliness.org/events/the-missing-million-in-search-of-the-loneliest-in-our-communities/

See also:

1http://www.campaigntoendloneliness.org/wp-content/uploads/CEL-Hidden-People-report-final.pdf

Junior Doctors’ Perspective on Lonelinessin the Older PopulationPoppy Mackay, Foundation Year 1 Doctor graduated from King’s College London with MBBS and aBSc (Hons) in Gerontology.

Grace Baxter, Foundation Year 1 Doctor graduated from Cardiff University with MBBCh and a BSc inPsychology in Medicine.

With an ageing population comes a greater risk of socialisolation and loneliness. It has been estimated by Jopling (2015)that around 10% of older people are ‘chronically lonely’ and AgeUK have found that over one million older individuals identifythemselves as being lonely (Age UK, 2016). Although lonelinesscan be objectively defined, the real impact of its definition is howthe word is interpreted by the individual. To be lonely in older agedoes not merely imply being physically alone.

Kileen (1998) stated that loneliness is under reported “in today’sself-obsessed climate, where it is seen as a negativeembarrassing condition.” However, junior doctors have a uniqueopportunity to care for people at their most vulnerable. Beingacutely aware of an individual’s social circumstance allows themto offer simple interventions to tackle loneliness.

Loneliness is not purely a social problem; it has been reportedthat it is a predictive indicator for a number of negative healthoutcomes such as depression, dementia and hypertension (AgeUK, 2016; Prina et al, 2013). Gerst-Emerson and Jayawardhana(2015) believe that a “targeting of interventions for lonely eldersmay significantly decrease physician visits and health carecosts”.

Loneliness is a growing problem in the United Kingdom as lifeexpectancies rise, transport links improve and there isglobalisation of the labour market. A combination of thesefactors has resulted in the breakdown of traditional socialnetworks. A recent review by Hagen et al (2014) discussed theeffectiveness of new technology as a positive intervention forloneliness. However, without the ability to utilize such services, aproportion of the older population is becoming increasinglysecluded in an ever more connected world.

The Role of the Junior DoctorThere are many simple interventions that can have a hugeimpact on how an individual perceives their situation. Duringhospital admissions, patients often report experiencing boredomand isolation. In particular, those undergoing long termadmissions who have had intense initial support whilst acutelyunwell often find that this is not sustained. However, juniordoctors are uniquely placed to be able to raise issues ofloneliness and its impact and create an environment where theycan be discussed openly. Encouraging family members andfriends to visit can help alleviate feelings of loneliness. Whilstward rounds can be overwhelmingly busy, a few minutes focusedon the mental well-being of a patient and their current emotionalstate can have a huge impact in how they view their care.

As a first step, patients can be referred to Liaison Psychiatricservices for assessment of their mood. In particular, if Older

Adult Liaison Psychiatry services are present in a hospital, theyare better equipped to understand the specific needs of olderindividuals.

Additionally, as an inpatient, individuals can be referred to theRoyal Voluntary Services who visit patients for a social chat inorder to reduce social isolation. In busy situations where doctorsmay not be able to give their patients the time needed, theseservices are an invaluable support to curb loneliness anddepression.

Age UK is an essential resource to many individuals. Not only dothey provide a vast amount of information and research on theageing population but they have practical groups addressingloneliness. Their befriending programme allows people to accesssocial situations they may have been previously isolated fromand to strengthen their friendship network. Another tool totackle loneliness in hospital is ‘The Silver Line’, a helpline forolder people that offers twenty four hour support. It is a freetelephone number that provides someone at the end of a phoneto interact with.

Spiritual support can also provide a vital resource to someindividuals but is often not addressed unless in the presence ofterminal illness. Most hospitals have access to spiritual leadersof all faith denominations, who can be contacted at the requestof patients.

In conclusion, there are many interventions available to the olderpopulation in order to tackle the growing problem of loneliness. Itis the role of junior doctors to further their understanding ofservices available and to take the time to address this issuewhilst patients are under their care.

Article

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ReferencesAge UK. (2016). Later Life in the United Kingdom. [Online] Available at:http://www.ageuk.org.uk/Documents/EN-GB/Factsheets/Later_Life_UK_factsheet.pdf?dtrk=true Age UK. (2016). Loneliness among older men with poor health a growing problem.[Online] Available at: http://www.ageuk.org.uk/latest-news/loneliness-among-older-men-growing-problem/Gerst-Emerson, K. and Jayawardhana, J. (2015). Loneliness as a Public Health Issue: TheImpact of Loneliness on Health Care Utilization Among Older Adults. American Journal ofPublic Health, 105(5), pp. 1013-1019. Hagan, R., Manktelow, R. and Taylor, BJ. et al (2014). Reducing loneliness amongst olderpeople: a systematic search and narrative review. Aging Mental Health, 18(6), pp.683-93. Holt-Lunstad, J., Smith, TB.and Layton, JB. (2010). Social Relationships and MortalityRisk: A Meta-analytic Review. PLoS Med 7(7), e1000316.Jopling, K. (2015). Promising approaches to reducing loneliness and isolation in later life.[Online] Available at: http://www.campaigntoendloneliness.org/wp-content/uploads/Promising-approaches-to-reducing-loneliness-and-isolation-in-later-life.pdfKilleen, C. (1998). Loneliness: an epidemic in modern society. Journal of AdvancedNursing, 28, pp.762–770.Prina, M., Huisman, M. and Yeap, B. et al (2013). Association between depression andhospital outcomes among older men. [Online] Available at:http://www.cmaj.ca/content/185/2/117.short

Dr Poppy Mackay Junior Doctor

Older Adult Liaison Psychiatry Team,Chelsea and Westminster Hospitals

Dr Grace Baxter Junior Doctor

Older Adult Liaison Psychiatry Team,Chelsea and Westminster Hospitals

References:Astrow, AB., Wexler, A., Texeira, MK., Kai He, M. and Sulmasy, DP. (2007). Is failure tomeet spiritual needs associated with cancer patients' perceptions of quality of care andtheir satisfaction with care? Journal of Clinical Oncology, 25(36), pp. 5753-5757.Best, M., Buttow, P. and Olver, L. (2015). Doctors discussing religion and spirituality: Asystematic literature review Palliative Medicine [online] Candy, B., Jones, L., Varagunam, M., Speck, P., Tookman, A. and King, M. (2012).Spiritual and religious interventions for well-being of adults in the terminal phase ofdisease. Cochrane Database of Systematic Reviews, Issue 5. Art. No.: CD007544. Holloway, M., Admanson, S., McSherry, W. and Swinton, J. (2011). Spiritual Care at theEnd of Life: a systematic review of the literature. University of Hull: Hull. The Departmentof Health. Leadership Alliance for the Care of Dying People. (2014). One Chance to get it Right.London.National Institute for Clinical Excellence. (2004). Supportive and Palliative Care for Adultswith Cancer. Department of Health: London.O’Brien, MR. and Clark, D. (2015). Spirituality and/or religious faith: A means for copingwith the effects of amyotrophic lateral sclerosis/motor neuron disease? Palliat SupportCare, 13(6), pp.1603-14.Paal, P., Leget, C. and Goodhead, A. (2015). Spiritual Care Education: Results from anEAPC Survey. European Journal of Palliative Care, 22(2), pp. 91-95.Yardley, S., Walshe, C., and Parr, A. (2009). Improving training in spiritual care: aqualitative study exploring patient perceptions of professional educational requirements.Palliative Medicine, 23(7), pp. 601-607.

autumn 2016 issue fifteen innov-age magazine 9

Dr Karen Groves MBEMedical and Education Director Queenscourt Hospice, Southport

Consultant in Palliative Medicine Southport and Ormskirk Hospital NHS Trust

Enhancing the recognition of spiritual needs andcare for patients: the value of the Opening theSpiritual Gate ProgrammeDr Karen Groves MBE is Medical and Education Director for Queenscourt Hospice in Southport and Consultantin Palliative Medicine for Southport & Ormskirk Hospital NHS Trust. She is also Chair of the Cheshire &Merseyside Network Spiritual Care Group. This group was developed to ensure implementation of the NICESupportive & Palliative Care Improving Outcomes Guidance, Spiritual Support Services, 2004.

Having a chronic debilitating condition, ageing, andapproaching the end of life, have been shown to raisequestions that may rekindle or intensify spiritual concerns.Some, mainly western world, evidence suggests positivebenefits between spiritual awareness and emotional/mentalhealth. Spiritual, and/or religious belief potentially helps aperson to cope, find meaning, purpose and peace of mind attheir impending death (Candy et al., 2012; O’Brien & Clark,2015). Patients state that they expect clinical staff to beinterested in them as individuals and address spiritual issues.They report less satisfaction with care when spiritual needs arenot met (Astrow et al., 2007, Yardley et al., 2009).

Policy BackgroundRecent policies stress the responsibility of healthcare workersin addressing the holistic and spiritual needs of patients andfamilies. Chapter 7 of The National Institute for ClinicalExcellence: Supportive and Palliative Care Improving OutcomesGuidance (2004) is dedicated to spiritual care. More recently,the Leadership Alliance for the Care of Dying People (2014)report stressed the need to address individual needs andconcerns of each patient and family. Furthermore, theDepartment of Health commissioned a systematic literaturereview of spiritual care at the end of life (2011) and theEuropean Association for Palliative Care (EAPC) Task Force onSpiritual Care in Palliative Care recommended that palliativecare professionals, and volunteers, need training to identifyspiritual needs and provide spiritual care (Paal et al., 2015).

Despite this policy background, clinical staff describe feeling illprepared, undereducated, uncomfortable and lacking in bothconfidence and skills for the task of addressing spiritual issuesand are unsure whether it is part of their role (Best et al.,2015; Candy et al., 2012; Holloway et al., 2011). With thepredicted rise in the elderly population, there is an evengreater need to ensure staff are adequately prepared toprovide this support.

Opening the Spiritual Gate ProgrammeCheshire & Merseyside Network, Spiritual Care Groupadapted an existing Queenscourt Hospice educationprogramme, developed it further and rolled it out over the lastdecade. In its 2015 survey, the EAPC Spiritual Care Task Forceidentified reference to this programme in a small number ofspiritual care training courses (Paal et al., 2015). Furthermore,it was recently described as a ‘significant training programme’by the Care Quality Commission inspection of the RoyalDevon and Exeter NHS Hospital Foundation Trust (February2016).

The programme aims to raise awareness of spiritual andreligious issues and needs as well as to encourage staff to: • foster understanding that spiritual care is everyone’s

business • discern what gives meaning to life and may be important to

those who are ill• demonstrate the diversity and individuality of spiritual and

religious needs • consider the importance of rituals and rites of passage • consider how to open, maintain and close a conversation

about spiritual issues • concisely and confidentially record and handover spiritual

and religious needs • devise a management plan for spiritual and religious care • be aware of resources available for meeting spiritual and

religious needs • plan the transfer of learning, and confidence gained, into

the workplace and to develop an action plan for individualdevelopment

The course is intended for frontline healthcare staff and isdelivered both face to face and online as an introduction tospiritual assessment and support for staff. For moreinformation see: www.openingthespiritualgate.net

Course evaluations to date have demonstrated the value tothe participants’ confidence and willingness to undertakespiritual conversation and assessments. Currently, anindependent evaluation of the impact on the courseparticipant’s clinical practice is being conducted by Edge HillUniversity.

Research

innov-age magazine issue fifteen autumn 201610

These days people can’t turn around without being told todo more exercise and with the Olympics just behind us, ithas been dominating the news. People are constantlyencouraged to hit the gym, jump on a bike or fit activityinto their daily routine in other ways, such as taking thestairs instead of the lift or getting off the bus a stopearlier. While most people are aware of the benefits ofphysical activity on their bodies, less is known about thebeneficial effects on their mental wellbeing.

Exercise is known to have positive physical, mental andemotional benefits. As the ability to undertake physicalactivity decreases in the elderly, incidence rates of anxietyand depression increase, as does impairment of memory,cognition and intelligence. These factors combined lead toa lower quality of life in the elderly population. A study in2014 has shown that increasing prevalence of depressionin the elderly correlates with increasing suicide rates inthis population (Lee et al., 2014).

Depression is a general health problem affecting thepublic and is associated with many physical diseases,including cardiovascular disease and diabetes (Carney etal., 2002). Symptoms can include a continuous low mood,anxiety, a decline in enthusiasm and motivation and sleepdisorders; it can also induce a decline in cognitive and

mental function. This can lead to difficulties in performingnormal daily tasks, both for personal care and around thehouse (van Milligen et al., 2011).

Regular exercise or physical activity has been shown toexert a positive influence on both the physical and mentalhealth of older people. It leads to improvements instrength, balance, flexibility and agility, cardiopulmonaryendurance and also creates psychological stability andhappiness (Park and Kim, 2011). Physical activity has alsobeen shown to reduce symptoms of mild and severedepression. A Korean study (Lee, 2015) showed that highlevels of physical performance were associated with lowlevels of depression in elderly women. The findings alsoindicated that strength, strength endurance,cardiorespiratory endurance level and improvements inagility could have positive outcomes on the symptoms ofdepression.

A study initiated by the Ministry of Health, Labor (sic) andWelfare in Japan led to a revision of the long-term careinsurance act in 2008 and greater emphasis onpreventative long-term care and associated activities(Maki et al., 2012). Three areas were selected as modelsto evaluate how effective community-based programmeswere against preventing mental decline. Takisaki wasselected as an area for an intervention-based walkingprogramme; the intervention was designed to testwhether a walking programme was effective in preventingmental decline in elderly individuals with no diagnosis ofdementia. The resulting randomised controlled studyshowed that the group that undertook the walkingprogramme benefited from improvements in word fluency,quality of life, social interaction and the ability to completephysical tasks. The benefits of undertaking theprogramme in a small group included enhancedmotivation, positive emotion and social interaction.

Exercise classes have also been shown to reduceloneliness and feelings of isolation. Social isolation hasbeen shown to be associated with a greater risk of mental

Get Up and Go for it!Why exercise can be good for your moodKate Bennett is a physiotherapist currently working as a Project Manager on the PhysiotherapyWorks programme for the Chartered Society of Physiotherapy (CSP) in the UK.

Prior to working for the CSP she worked as a physiotherapist in Salisbury specialising in elderlyrehabilitation and treating falls and balance issues in the elderly.

Kate is vice chair of AGILE – the association for physiotherapists working with the elderly.

autumn 2016 issue fifteen innov-age magazine 11

ReferencesBarton, J. and Pretty, J. (2010). What is the Best Dose of Nature and GreenExercise for Improving Mental Health? A Multi-Study Analysis. Environ. Sci.Technol. 44(10), pp.3947–3955.Bassuk et al. (1999). Social disengagement and incident cognitive decline incommunity-dwelling elderly persons. Ann Intern Med. 131(3), pp.165-173.Carney et al. (2002). Depression as a risk factor for cardiac mortality andmorbidity: A review of potential mechanisms. J Psychosom Res. 53, pp.897-902.Krishnamurthy M.N, and Telles, S. (2007). Assessing depression following twoancient Indian interventions: effects of yoga and ayurveda on older adults in aresidential home. J Gerontol Nurs. 33(2), pp.17-23.Lee et al. (2014). Association between depression and physical fitness, bodyfatness and serum vitamin D in elderly population. Korean J Obes. 23, pp.125-130.Lee, H. and Park, J. (2015). Effects of Nordic walking on physical functions anddepression in frail people 70 years and above. J Phys Ther Sci. 27(8), pp.2453-2456. Lee, Y.C. (2015). A study of the relationship between depression symptom andphysical performance in elderly women. J Exerc Rehabil. 11(6), pp.367-71.Maki, Y., et al. (2012). Effects of intervention using a community-based walkingprogram for prevention of mental decline: A randomized controlled trial. JAGS, 60,pp.505 – 510.Park, I.S. and Kim, Y.H. (2011). Influence of line dance participants’ physical elf-efficacy and health promotion acts in mental happiness. J Sports Leis Stud. 43,pp.127 – 139.Patel, N., et al. (2012). The effects of Yoga on physical functioning and healthrelated quality of life in older adults: A systematic review and meta-analysis. AlternComplement Med. 18(10), pp.902-917.Suija et al. (2009). Physical activity of depressed patients and their motivation toexercise: Nordic walking in family practice. Int J Rehabil Res, 32, pp.132-138.Van Milligan et al. (2011). Objective physical functioning in patients withdepressive and/or anxiety disorders. J Affect Disord ,131, pp.193-199.Wallace, R., et al. (2014). Effects of a 12-week community exercise programme onolder people. Nursing Older People. 26(1), pp.20-26.Wilson, R.S., et al. (2007). Loneliness and risk of Alzheimer disease. Arch GenPsychiatry. 64, pp.234 – 240.

decline (Bassuk et al., 1999; Wilson et al, 2007). In 2014,a study was published showing that older people whoundertook a 12 week community exercise programme feltthat the programme reduced social isolation (Wallace etal., 2014). This finding has two aspects; firstly participantsfelt the programme provided structure and allowed themto meet new people, gain social support and feel caredfor. Secondly, the programme provided them with physicalbenefits that increased their ability/motivation to socialisewithin existing networks and groups.

So what does exercise or physicalactivity actually entail? For manypeople the thought of donningbrightly coloured lycra andpumping iron at the gym is notappealing. Fear not! Physicalactivity comes in many shapes orforms and people can choosewhat suits their level of fitness orwhat fits into their lifestyle.

Ways to increase activity levelscan include the following:• Gardening• Housework/chores• Walking to the shops rather than driving/getting the bus

• Joining the local gym

Before choosing to join a localgym, people should have a chatwith their GP to discuss any activities/machines theyshould avoid or be careful of. It could be an idea to bookan initial session with a personal trainer who can helpdevise a suitable and effective programme.

There is also the option to take up specific activities suchas strength and balance classes, yoga or Tai Chi. Yoga inparticular has been shown to have a number of healthbenefits such as improvements in walking and balance,muscle strength and cardiovascular fitness, as well asimprovements to quality of life and psychosocial benefitsthrough the prevention and control of common health andemotional problems linked with ageing. A review of theliterature around yoga by Patel et al., 2012 showed thattaking part in yoga led to substantial improvements inindividuals’ abilities to undertake daily household chores,and the symptoms of depression were reduced at both 3and 6 months after the intervention took place(Krishnamurthy and Telles, 2007).

Two further studies have shown that older people whoundertake regular Nordic walking sessions have reportedimproved mood and a reduction in depressive symptoms(Suija et al., 2009). These findings also support the theory

that outdoor exercise has a greater effect on stabilisingpeople psychologically then exercising indoors. Outdoorexercise programmes involving group activities have beenshown to be more effective at improving depression thanindoor exercise groups (Lee and Park, 2015).

The effect of nature on mental wellbeing should also notbe underestimated. A multi-study analysis carried out byBarton and Pretty (2010) showed that exercising in thepresence of nature leads to both short and long term

health benefits. The presence of water appeared toenhance these effects.

There is no doubt from the evidence above thattaking part in physical activity or exercise of somekind enhances people’s mood and alleviatesdepression in all age groups including older adults.There are many misconceptions around whatconstitutes exercise and this can often put peopleoff increasing their physical activity. The importantthing to remember is that people need to dosomething enjoyable and suitable to their currentlevel of fitness. If they love the outdoors, theyshould consider increasing the time they spendgardening or maybe look for a local walking groupin their area. If they love to socialise, they shouldlook for local exercise classes where they canmeet new people. Exercise remains an importantaspect of maintaining not just physical but mentalwellbeing, especially into later life, and the morepeople can be encouraged to be active, the better

they will feel.

Kate Bennett Project Manager

Physiotherapy Works programme for theChartered Society of Physiotherapy

innov-age magazine issue fifteen autumn 201612

News

An active lifestyle = better brain health The Global Council on Brain Health is a new independent collaboration of scientists,doctors, scholars and policy experts from around the world, created by AARP – theleading US not-for-profit organisation for people aged 50 and above – in collaborationwith Age UK. Their first report, released in July 2016, looks at physical activity andbrain health.

Your chance to let us know yourthoughts and comments!

What topics would you like to see featured? What doyou see as important eldercare issues that need to beaddressed? What improvements would you suggest andwhat do you particularly enjoy about Innov-agemagazine?

We would love to hear your views and act upon them!

Please visit the following link and complete the onlinesurvey to provide your much valued input and feedback:http://www.surveygizmo.com/s3/3094913/Innov-age-Feedback

Those with a hard copy may alternatively choose tocomplete the printed version and return via the freepostenvelope.

Innov-age magazine has now been running for 14 issues and over that time has coveredthe topics of: Incontinence, Falls, Dementia, Telehealth, MSK, Stroke, Pain, Long TermConditions, Exercise, Sight, Hearing, Heart Health, Diabetes and End of Life Care.

All qualifying entrants will be placed into a prize draw towin a £50 One4all Gift Card, accepted by over 22,000retailers in the UK (closing 9th December). Please referto the full T&Cs here:http://www.trustech.org.uk/innovage-survey/

The report provides five evidence-based statementsagreed by the expert group on the relationshipbetween exercise and brain health as we age:

1. Physical activity has a positive impact on brainhealth.

2. People can change their behaviour to becomemore physically active at any age.

3. Based on randomized controlled trials, people whoparticipate in purposeful exercise show beneficialchanges in brain structure and function.

4. Based on epidemiological evidence, people wholead a physically active lifestyle have lower risk ofcognitive decline.

5. In spite of the link between physical activity andbrain health, there is not yet sufficient scientific

evidence that physical activity can reduce risk ofbrain diseases that cause dementia (e.g.Alzheimer’s disease).

People therefore have the power to protect theirbrains against ageing by taking part in regularexercise. What’s more it is never too late to start andpeople can change their behaviour to become moreactive at any age, reaping the beneficial changes tobrain structure and function.

Practical advice and recommendations on ways toincrease activity and the amount we should be aimingfor per week are also included.

To read the report in full, please visit: http://www.ageuk.org.uk/Documents/EN-GB/For-professionals/Research/GCBH-The-Brain-Body-Connection-Report-Jul16.pdf?dtrk=true

autumn 2016 issue fifteen innov-age magazine 13

The Future of Ageing Conference 9th November 2016 The International Longevity Centre – UK hosts this conference in London to bring together Government,industry, academia and civil society in order to discuss the implications of our ageing society.http://www.futureofageing.org.uk

Transforming Mental Health and Dementia Provision with the Natural Environment10th November 2016 This one day conference organised by The Centre for Sustainable Healthcare takes place in London. Itlooks to discuss practical ways to allow the adoption of nature-based interventions into mainstream healthand social care provision in order to help tackle mental health issues and dementia.https://www.eventbrite.co.uk/e/transforming-mental-health-and-dementia-provision-with-the-natural-environment-tickets-26751465353?aff=es2

For Later Life Conference 8th February 2017 This one day conference hosted by AGE UK takes place in London to discuss the latest developments inage-related policy and practice.http://www.ageuk.org.uk/professional-resources-home/conferences/forlaterlife/

The Mental Capacity Act in Dementia Care – 1 day Masterclass 8th December 2016 This one day master class hosted by the Association for Dementia Studies takes place at the University ofWorcester. It will explore how the Mental Capacity Act relates to the everyday practice and dilemmas thatoccur in dementia care. Open to all health and social care staff who work with people living with dementia.https://www.eventbrite.co.uk/e/dementia-one-day-masterclass-mental-capacity-act-8-december-2016-registration-25788474020?aff=es2

Upcoming Events…

Volunteering in later life may enhancemental health and wellbeing A study from researchers at the University of Southampton and University ofBirmingham who reviewed data from the British Household Survey has found apotential link between volunteering and improved mental wellbeing over the age of 40.

Previous research has suggested that freely giving time tohelp others can boost self-wellbeing but has mainly focussedon older adults. This study aimed to examine the affectsacross the whole life course. They found that the associationbetween mental wellbeing and volunteering varied accordingto age and did not emerge until later in life. During early-midadulthood taking part in volunteering activities did not appearto have any significant positive benefit on mental wellbeing.However, once over the age of 40-45, mental health scoresimproved for those who took part in volunteering activitywhilst getting worse for those who didn’t.

However, as pointed out in NHS Choices (2016) it’simportant to bear in mind that it’s not necessarily the casethat the volunteering has caused the good state of health. Itcould be that the association works both ways – betterwellbeing probably makes you more inclined to help others,and helping others probably boosts your sense of wellbeing.

For more information please see:http://bmjopen.bmj.com/content/6/8/e011327 http://www.nhs.uk/news/2016/08August/Pages/Volunteering-may-boost-mental-wellbeing-in-older-adults.aspx

News

innov-age magazine issue fifteen autumn 201614

Article

Living Longer, Living BetterTricia Grierson was appointed to the role as Head of Independent Living in 2015 but has worked forJohnnie Johnson Housing Trust (JJHT) for 14 years. It is a strategic role, leading the development of anew offer for residents over the age of 50. The aim is to position JJHT as a market leader forIndependent Living in social housing, delivering outstanding services for current residents and beingthe most attractive option for future customers.

Tricia has worked in the field of Social Housing since 1985. She is a Fellow of the Chartered Instituteof Housing, a Board member of Women in Social Housing (North West) and a Trustee of Age UKCheshire East.

Johnnie Johnson Housing Trust (JJHT), founded by thefighter pilot Air Vice Marshall James Edgar ‘Johnnie’Johnson in 1969, is rapidly approaching its 50th Anniversary.It now has 5000 homes across the country, mainly in theNorth of England. Over 3000 properties are designated forpeople aged 50+ with support also provided for many otherolder people living in their family homes. In 2000, JJHTestablished their Social Alarm centre called Astraline whichprovides telecare support for over 60 housing associationsand other agencies across the UK. Astraline has recentlybeen accredited to Platinum status with the TSA (TelecareServices Authority), one of only 29 Telecare Alarm ReceivingCentres in the UK to achieve this status. Staff from the Trustand Astraline work jointly to deliver a unique service to theresidents.

Until 2015, JJHT delivered a traditional service to theirsheltered housing schemes with a full-time scheme managerbased at just one scheme. They have, however, recentlyreviewed their services as a result of regulatoryrequirements, and commissioned an independentconsultation with their residents. The residentsdemonstrated a very strong brand loyalty to the Trust andwere very happy with their homes but wanted increasedchoice and better value for money, especially with servicecharges.

This review led to the creation of their new vision “LivingLonger Living Better” – helping the residents to age well,live independently and maintain their quality of life for aslong as possible. JJHT are focussing on ‘Independent Living’for residents of over the age of 50, many of whom may notneed support at the moment but are preparing for theirfutures.

As a consequence of the new vision, the Trust havetransformed their organisation and restructured the wholeIndependent Living service to offer a flexible approach todeliver targeted services. The aim is to offer a menu ofchoice to residents so that they can select the level and typeof service they need, with the option to extend or vary thisas their needs change. Striving to deliver value for money,

the restructure has enabled a reduction in service chargesfor 2016/17 and with carefully negotiated procurement theywill continue to reduce costs.

JJHT Connections is vital to their Independent Living offerbringing together residents, staff and partners, both inperson and virtually. The diagram below shows the differentelements of the offer which can be delivered. They fulfil theneeds of current residents whilst being attractive andfinancially viable for future younger customers. A coreservice is delivered to all tenants, additional services areavailable in their Independent Living schemes and they arenow preparing an offer of services including assistivetechnology. Residents can select from a range of services toenable them to enjoy staying independent for longer. Suchofferings may be provided by the Trust or partnerorganisations that JJHT help tenants to connect with.

InvestmentMaximising the use of new technology, JJHT now have agileworking Independent Living Coordinators (ILCs) who deliverservices and information to people in their own homes. Thefocus of their role is now more outward looking, working withthe wider community to facilitate health and well-beingactivities for residents and their local neighbours. They are

autumn 2016 issue fifteen innov-age magazine 15

Patricia Grierson Head of Independent Living

Johnnie Johnson Housing Trust

creating supportive communities (rather than supported)that engender independence to create a preventativeservice, rather than a reactive or one-size-fits-all approach.

Services are being re-focused based on individual residents’data that they have shared about their medical and supportneeds, and the levels of outgoing calls to Astraline, etc.Moving from a blanket service of morning calls for alltenants, JJHT can now offer more tailored solutions such asalternative methods of contact. This allows the ILCs moretime to deliver a face to face service to those who reallyneed it.

This aim to tailor services to customers’ needs and create aflexible service approach, meant JJHT needed to understandmore about their customers. From knowledge and data abouttheir residents, they are creating a number of key customerprofiles or ‘personas’ such as:

• Pete – the 58 year old single man in the IndependentLiving scheme with limited family contacts anddecreasing social life other than going alone to the pub.

• Betty – the 85 year old lady in the Independent Livingscheme with no obvious health issues, out and aboutevery day volunteering to help others with no check calls.

• James & Irene – a couple in their mid-70s living in abungalow with a social alarm where one partner is thecarer for the other and feels very isolated.

• Jon & Jane – future residents – a couple in the late 40swith no children who are considering their future options

The aim is to promote these key personas across thebusiness, using them to understand customers’ needs, habitsand worries and shape what JJHT or their partners could dowith the services they offer. Personas help the staff toidentify with residents, avoiding generalisations andassumptions that could lead them to believe that one offerwould suit all. For example where they have a number of‘Petes’ in their schemes, JJHT are putting on some malespecific activities – art classes is one idea they are currentlytrialling. Where they have elderly and independent ‘Bettys’they are testing some new Astraline Telecare technologywhich is not intrusive, but there as a “comfort” for thecustomer, or their family, knowing that if ‘Betty’ fell, Astralinewould be alerted and they could respond immediately.

The approach to developing the service offer has been topilot new ideas in a range of different schemes. The pilotscover:

• Alternative options to the morning check call• Greater use of assistive technology • Targeted personal visits • Safe and secure packages (individual home safety

checks, security measures, adaptions) • Social activities to combat loneliness and isolation,

particularly in men

Planning for our future The future is looking positive for JJHT and its residents.They are starting to plan the development of new properties,creating modern practical homes with innovative flexibledesigns. They will maximise the opportunities available frominnovative development in assistive technology, allowing theresidents to live independently for longer in their own homes.

Astraline is the first alarm receiving centre in the UK toimplement the SCAIP protocol (Social Care Alarm InternetProtocol). JJHT have reviewed their IT infrastructure makingconsiderable investment so that as technology develops theywill have ample capacity to receive calls over the internet.This will entail no call charges to any of their customers,making the service much better value for money. In thefuture they will be able to have face to face communicationwith their customers and provide them with the ability to dothis with each other as well as with their families, friends andeven GPs.

JJHT have properties located in very rural areas where evenanalogue lines are not always reliable. Astraline has beenworking with B4RN (Broadband for the Rural North) whoprovide fibre optic cable, supplied with a battery back-up, toenable such properties to access extremely high speedbroadband connections 100% of the time.

Finally, looking into the more distant future, JJHT is keen toensure that the properties and services that they have beendeveloping for the past fifty years will still be relevant andvaluable for the next 50 years. To that end, they are workingwith Newcastle University’s Institute for Ageing to test outin practice their views about future needs and requirementsof older people for services and homes in 2030+. JJHT isstriving to ‘future proof’ its service so that it fulfils theaspirations of younger generations to come.

innov-age magazine issue fifteen autumn 201616

Loneliness in later life: opportunitiesand challenges for intervention Nicole Valtorta is a Research Fellow in Public Health at the University of York, currently funded bythe National Institute for Health Research to study for a PhD on loneliness, social isolation andthe risk of cardiovascular disease.

Professor Simon Gilbody founded and directs the Mental Health and Addictions Research Groupat the University of York’s Department of Health Sciences.

In the UK, persistent loneliness in later life affects 14.5%of adults aged 65 to 79, and close to 30% of those aged80 and over (Office for National Statistics, 2015).Commonly defined as the perception that one’srelationships are quantitatively and/or qualitativelydeficient (de Jong Gierveld & al., 2006), this negativefeeling, when it becomes chronic, is associated with arange of poor health and wellbeing outcomes. Lonelyindividuals are, on average, 26% more likely to dieprematurely - an effect size exceeding the increased riskof mortality associated with physical inactivity or highBody Mass Index (Holt-Lunstad & al., 2015). Recentsystematic reviews of the evidence have identifiedloneliness as a risk factor for some of the greatestcauses of morbidity worldwide, including cardiovasculardisease and dementia (Kuiper & al., 2015; Valtorta & al.,2016). Three main health-damaging pathways have beenevidenced: psychological distress, behaviours such assmoking and poor diet, and physiological mechanisms(Berkman & Krishna, 2014).

What are the implications of what we knowabout loneliness and health in older age forprevention strategies?Policy makers in UK and other countries have begun torecognise the public health challenge associated withpersistent loneliness, and with the more objectivesituation of social isolation. In 2012, the White PaperCaring For Our Future explicitly identified loneliness as akey societal concern: ‘Loneliness and social isolation remains a huge problemthat society has failed to tackle…Social isolation and persistent loneliness, particularly inlater life, have a huge impact on people’s health andwellbeing… We must work together to tackle socialisolation’ (Department of Health, 2012).

Recognising poor social relationships as a societalchallenge concern is a first step in tackling the problem –the next stage is to identify the best strategies foraddressing such a multifaceted issue. In this article,

drawing on evidence from observational and evaluativestudies, we discuss opportunities for prevention, andassociated challenges.

1. Targeting at-risk groups Chronic loneliness in older age is not inevitable. Certaincircumstances, which people in later life are more likelyto face, can act as triggers: the loss of a spouse,retirement, becoming a carer, declining health and entryinto care have all been associated with a decrease in thequality and/or quantity of a person’s social relationships(Dykstra & al., 2005). In recognition of these risk factors,much of the intervention effort to date has focused onpeople with a long-term condition or limited mobility,bereaved individuals, nursing home residents, retirementcommunity residents, and caregivers (Dickens & al.,2011).

Comparatively less attention has been given to factorswhich, earlier in life, can lead to persistent lonelinessinto later age. These include some of the most importantdeterminants of social inequality, such as lower socio-economic status, unemployment and migration (PublicHealth England, 2015). Lower education level, lowerincome and chronic work and/or social stress have alsobeen associated with heightened levels of loneliness(Hawkley & al., 2008). From the perspective ofopportunities for intervention, this suggests thatinitiatives aimed at improving people’s social andeconomic circumstances have the potential to tackleloneliness. It also highlights the pertinence of actionearlier in the life-course to tackle loneliness in older age(see Figure 1. for a summary of opportunities forinterventions across key stages of the life course).

2. Designing and implementing tailoredinterventions A wide range of interventions have been developed tocombat loneliness. These include group activities (e.g.choir practices, writing clubs. exercise sessions), one-to-one interaction (e.g. home visits, befriending), and

Research

autumn 2016 issue fifteen innov-age magazine 17

Professor Simon Gilbody Mental Health and Addictions Research Group

Department of Health Sciences, University of York

technology-based solutions (e.g. computer and internettraining). To date, because few of these interventionshave been robustly evaluated, their effectiveness intackling persistent loneliness is unclear. Systematicliterature reviews have identified that, in general,initiatives underpinned by a theoretical framework, andactions whose design and delivery actively involveparticipants, are more successful; but no single type ofintervention has been shown to be effective acrosstarget groups (Dickens & al., 2011).

Given the range of experiences that can lead to chronicloneliness, it is likely that different circumstances willrequire different interventional approaches. Lonelinessstemming from the perceived absence of a confidant(emotional loneliness) differs from loneliness derivingfrom the perceived absence of a wider social network(social loneliness) (van Baarsen & al., 2001). Befriendingwould seem more suited to the former while groupactivities may be more appropriate for the latter. Thechallenge for interventions is to take into account thisplurality of experiences, and tailor actions accordingly. Apromising example of how this might be done is the‘Reconnections’ service set up by Age UK Herefordshireand Worcestershire in 2015, whereby individuals

identified as being lonely or isolated through local socialcare, healthcare and community networks co-produce anaction plan with the charity to strengthen their socialrelationships (http://www.reconnectionsservice.org.uk).Ongoing evaluation of this service includes monitoringeffects on loneliness but also health outcomes;information that will help to further our understanding ofwhether initiatives tackling loneliness can help improvehealth and wellbeing.

3. Implications for patient care The evidence linking loneliness to health and wellbeingsuggests that social relationships should be taken intoaccount when caring for patients and service users.Social relationships can be used as a lever to promoteand support improvements in behaviours relating tohealth such as physical exercise, diet and smokingcessation. Effects on physiological functioning couldreduce the effectiveness of treatments, whileinterventions relying on the involvement of closerelationships in medical care have the potential topositively effect adherence to advice and medication(Holt-Lunstad & Smith, 2016).

Nicole Valtorta ,

Research Fellow in Public Health

Department of Health Sciences, University of York

Figure 1. Opportunities for strengthening social relationships across the life-course. Source: Public Health England (2015) Local action on health inequalities report: Reducing social isolation across the lifecourse, p.28

…continued on next page

• Inadequatesocialnetworks

• Maternaldepression

• Adverse childhood experiences• Being bullied• Being a young carer• Being not in employment,

education or training (NEET)

• Being unemployed• Experiencing relationship

breakdown• Poor social networks• Being a caregiver

• Bereavement• Loss of mobility• Poor quality

living conditions• Being a carer

Ch

alle

ng

es

• Programmesto providesupportduringpregnancy

• Parenting programmes• Programmes to support the home to

school transition• Building children and young

people’s resilience in schools• Support for young carers• Strategies to reduce NEETs

• Back to workprogrammes

• Programmes to supportskills development toincrease employability

• Support for carers

• Promote goodquality work forolder people

• Provision of socialactivity

• Support for carers• Support for the

bereaved

Key

are

as f

or

loca

l act

ion

Lifecourse stage:Pregnancy Early Years Working ageChildhood and

adolescenceRetirement and

later life

Certain individuals or groups are more vulnerable than others depending on factors such as physical or mental healthand the social determinants of health inequalities including income, education, occupation, social class, gender,race/ethnicity.

Improvement of the built and natural environment is likely to have impact across all stages of the lifecourse. Targetedprogrammes for particular groups, for example, supporting the transport needs of older people, improving the homes ofthe most vulnerable and targeting deprived areas, according to the principle of proportionate universalism, can help toreduce social isolation for those most at risk of social isolation.

ReferencesBerkman, L. F. and Krishna, A. (2014). Social network epidemiology. In: Berkman, L. F.,Kawachi, I. and Glymour, M. M, ed., Social Epidemiology, New York: Oxford UniversityPress, pp.234–89.De Jong Gierveld, J., Van Tilburg, T. G. and Dykstra, P. A. (2006). Loneliness and socialisolation. In: Vangelisti, A. & Perlman, D., ed., Cambridge Handbook of PersonalRelationships. Cambridge, UK: Cambridge University Press, pp.485-500.Department of Health. (2012). Caring for our future: reforming care and support, London,UK:The Stationery Office.Dickens, A. P., Richards, S. H., Greaves, C. J. and Campbell, J. L. (2011). Interventionstargeting social isolation in older people: a systematic review. BMC Public Health, 11,p.647.Dykstra, P.A., van Tilburg, T.G., de Jong Gierveld, J. (2005). Changes in older adultloneliness: results from a seven-year longitudinal study. Research on Aging, 27(6),pp.725-747.Hawkley L,C., Hughes, M.E., Waite, L.J., Masi, C.M., Thisted, R.A., Cacioppo, J.T.(2008). From social structural factors to perceptions of relationship quality and loneliness:the Chicago health, aging, and social relations study. The Journals of Gerontology. SeriesB, Psychological Sciences & Social Sciences, 63(6), S375-84. Holt-Lunstad, J., Smith, T. B., Baker, M., Harris, T. and Stephenson, D. (2015). Lonelinessand social isolation as risk factors for mortality: a meta-analytic review. Perspectives inPsychological Science, 10(2), pp.227-237.Holt-Lunstad, J. and Smith, T.B. (2016). Loneliness and social isolation as risk factors forCVD: implications for evidence-based patient care and scientific inquiry. Heart, 102,pp.987-989.Kuiper, J. S., Zuidersma, M., Oude Voshaar, R. C., Zuidema, S. U., Van Den Heuvel, E. R.,Stolk, R. P. and Smidt, N. (2015). Social relationships and risk of dementia: A systematicreview and meta-analysis of longitudinal cohort studies. Ageing Research Review, 22,pp.39-57.Office for National Statistics. (2015). Measuring National Well-being: Insights intoLoneliness, Older People and Well-being. London, UK. Public Health England. (2015). Local action on health inequalities report: Reducing socialisolation across the lifecourse. London, UK.Valtorta, N.K., Kanaan, M., Gilbody, S.M., Ronzi, S. and Hanratty, B. (2016). Lonelinessand social isolation as risk factors for coronary heart disease and stroke: systematicreview and meta-analysis of longitudinal observational studies. Heart, 102, pp.1009-1016.Valtorta, N.K., Kanaan, M., Gilbody, S.M. and Hanratty, B. (2016). Loneliness, socialisolation and social relationships: what are we measuring? A novel framework forclassifying and comparing tools. BMJ Open, 6 (4), 10.1136/bmjopen-2015-010799.Van Baarsen, B., Snijders, T., Smit, J.H., Van Duijn, M.A.J. (2001). Lonely but not alone:emotional isolation and social isolation as two distinct dimensions of loneliness in olderpeople. Educational & Psychological Measurement, 61, pp.119–135.

In elderly care and family practice, if lonely and isolatedpatients are being treated more often than others, thenhealth practitioners are well placed to play a key role inidentifying those at highest risk. One of the challengesthis raises is developing a means of assessment thatcaptures the multifaceted nature of loneliness whilstbeing easily incorporated into day-to-day practice.Because individuals may not wish to publicly admit tofrequent loneliness feelings due to stigmatization, usinga direct single question is unlikely to be sufficient. Avariety of tools exist to measure various socialrelationship dimensions (Valtorta & al., 2016) –familiarity with these is likely to require that socialrelationships and associated social circumstances becovered in medical, nursing and social care education(Holt-Lunstad & Smith, 2016).

As responses to the challenge of persistent lonelinessin later life develop, it will be important to monitor andevaluate their effects. Effective cooperation betweenpolicy-makers, the third sector, practitioners, serviceusers and researchers will be key to furthering ourunderstanding of how best to tackle this public healthand societal challenge.

DepressionSurprisingly there is relatively little research into determiningeffective treatments for depression in older people.

A review of psychotherapy (talking treatments) included onlyseven small studies, involving a total of 153 participants. Theresults indicated that a form of cognitive behavioural therapy(CBT) was more effective than no treatment at all but there wasno difference in depressive symptoms between CBT andpsychodynamic therapy.

Reviews of studies of antidepressant drugs involving about 2000people show that antidepressant drugs appear to be effective inthe treatment of older community patients and inpatients likelyto have severe physical illness. At least six weeks ofantidepressant treatment is recommended to achieve optimaltherapeutic effect. Remaining on antidepressant drugs for oneyear appears to reduce the risk of depression returning but thebenefits at other time intervals has not been determined.

Antidepressant treatment appears to be as well tolerated asplacebo (fake) treatment.

A lack of research as highlighted by this article indicates anurgent need for more high quality research in this underrepresented area.

• Wilkinson P, Izmeth Z. Continuation and maintenancetreatments for depression in older people. CochraneDatabase of Systematic Reviews 2012, Issue 11. Art. No.:CD006727. DOI: 10.1002/14651858.CD006727.pub2.

• Wilson K, Mottram PG, Vassilas C. Psychotherapeutictreatments for older depressed people. Cochrane Databaseof Systematic Reviews 2008, Issue 1. Art. No.: CD004853.DOI: 10.1002/14651858.CD004853.pub2.

• Wilson K, Mottram PG, Sivananthan A, Nightingale A.Antidepressants versus placebo for the depressed elderly.Cochrane Database of Systematic Reviews 2001, Issue 1.Art. No.: CD000561. DOI: 10.1002/14651858.CD000561.

The Cochrane Collaboration is an international network of more than 28,000 dedicatedpeople from over 100 countries. They work together to help healthcare providers, policy-makers, patients, their advocates and carers, and the general public make well-informeddecisions about health care, by preparing, updating, and promoting the accessibility ofCochrane Reviews.

Research

innov-age magazine issue fifteen autumn 201618

Cochrane Corner

autumn 2016 issue fifteen innov-age magazine 19

Tracey Howe Professor of Rehabilitation Sciences at Glasgow Caledonian University, Director Cochrane Global Ageing and Editor forthe Cochrane Musculoskeletal Review Group

Why is Cochrane Global Ageing required? The number ofolder people (over 65) is currently at its highest level inhuman history. Indeed, the World Health Organisation(WHO) has responded to global population ageing throughseveral important publications. One of these is the WHOGlobal Network of Age-friendly Cities and Communitieswhich was established in 2010 to connect cities, communitiesand organizations worldwide with the common vision ofmaking their community a great place to grow old in.

The United Nations member states recently signed up toGlobal Sustainable Development Goals. One of these isdevoted to “ensure healthy lives and promote well-being forall at all ages”.

Cochrane Global Ageing’s call to action is to challengenegative stereotypes and misconceptions about olderpeople by highlighting the need for and producing ageappropriate research and evidence. The team wants toensure older people are meaningfully and statisticallyrepresented in research studies and are included in theprocess of clinical trial development, dissemination andimplementation of results.

For more than 20 years, Cochrane has produced systematicreviews of research in health care and health policy.Systematic reviews are a type of literature review thatcollect and summarize the best evidence from research tohelp in making informed choices about treatment.

Cochrane reviews are internationally recognized as thehighest standard in evidence-based health care resources.The reviews investigate the effects of interventions forprevention, treatment, and rehabilitation. They also assessthe accuracy of a diagnostic test for a given condition in aspecific patient group and setting. They are published onlinein the Cochrane Library: http://www.cochranelibrary.com

Cochrane works collaboratively with contributors aroundthe world, including 37,000 people from more than 130countries. Cochrane reviews have helped to transform theway health decisions are made across the globe.

One of the first projects for Cochrane Global Ageing is tocompile a list of topics relevant to global ageing andgenerate and publish appropriate high quality informationas entries on Wikipedia. The call to action for readersis to please send your suggestions for Wikipediaentries on global ageing.

Cochrane Global Ageing will be writing Cochrane Corners,similar to the ones published in Innov-age, which summarizethe evidence from Cochrane reviews on particular topics.

The team will work with their network to identify prioritiesfor new Cochrane reviews on topics related to GlobalAgeing. Another call to action for readers is toplease send any questions requiring an answerabout the effectiveness of a treatment related toglobal ageing.

Questions usually take the form of – how effective is[treatment A] compared to [treatment B] or [no treatment]on the [goal of the treatment] in a [certain group of people]. Examples of this structure: • What are the effects of [exercise] compared with [no

exercise] on [balance] in [older people, aged 60 andover, living in the community or in institutional care].

• How effective are [different types of psychotherapytreatments] in the treatment of [depression] in [olderpeople].

Visit the website, www.globalageing.cochrane.org, to seelinks to resources relevant to global ageing includingresearch groups and organizations, conferences andfunding.

Cochrane Global Ageing will be using social media such astwitter to help start and spread conversations about globalageing. They will create Twitter lists and hashtags. Followthem @CochraneAgeing

For further information sign up to theirnewsletters or email globalageing@cochrane.org

Introducing Cochrane Global AgeingA new initiative - Cochrane Global Ageing - hasbeen launched on 1 October 2016 to coincide withthe United Nations International Day of OlderPersons. Its mission is to connect people andfacilitate sharing of knowledge and experiences related to global ageing andhealth that are relevant and accessible to the public, scientists, healthprofessionals, policy makers, educators, commissioners, journalists and funders.

innov-age magazine issue fifteen autumn 201620

Article

Can video-calls help prevent loneliness for carehome residents at risk of cognitive decline?Sonam Zamir is a PenCLAHRC (linked with the National Institute of Health Research) funded PhD student atPlymouth University. Her research is focused on the implementation of video-calls to help preventloneliness and social isolation, for care home residents at risk of cognitive decline. She has anundergraduate degree in Psychology and an MSc in Psychology, Health and behaviour from BrunelUniversity London.

Her supervisory team comprises Professor Ray Jones, Health Informatics and Professor Adrian Taylor,Health Services Research, both at Plymouth University, as well as Professor Catherine Hennessy, VisitingProfessor at Bournemouth University.

Social isolation is the lack of 'structural' and 'functional' socialsupport. Structural social support is normally assessedthrough the size of networks and frequency of contacts.Functional social support is a subjective judgment of thequality or perceived value of emotional, instrumental andinformational support provided by others. Loneliness is asubjective concept resulting from a perceived absence or lossof companionship. The need for companionship and to feelrelated to others is a core human need (Deci & Ryan 2008).

Loneliness and social isolation among older adults has thepotential to increase the risk of cognitive decline and eventhe risk of death (Dickens et al., 2011). Older residents incare homes and in community hospitals can be sociallyisolated and feel lonely with insufficient family contact. Familysupport may prevent depression (Masi et al., 2011) butfamilies may live far away and find it difficult to makefrequent visits. Seeing the talking faces of family membersmay aid older people’s memory whilst reducing loneliness andincreasing quality of life and well-being. Technologicalinterventions, such as video-calls, help to keep peopleconnected who may find it difficult to see one another face-to-face.

Socialisation interventions incorporating face to facecommunication through Skype have been developed, andtested among older adults living alone with cognitive decline.This type of socialisation intervention has been demonstratedto be beneficial and enjoyable amongst older people, and hasproved positive in increasing their social networks over along-term period (Jimison et al., 2013). Post interventionfollow-up of using Skype amongst older adults to reducedepression and loneliness has proven to be valuable in thetreatment of depression (Choi et al., 2014).

Even so, older people and their family may be concerned thatvideo calls may replace face-to-face visits (Tiberto et al.,2013). Improving the quality and quantity of social contactsmay help in maintaining quality of life both of people withdementia and their families (Golden et al., 2009; Bamford &Bruce, 2000). However, it is not clear if the capability forvideo calls improves overall quantity and quality of contactand there is a need to explore this further.

In 2013, the development of a ‘Skype on Wheels’ (SoW)device was undertaken as part of a proof of concept study byProfessor Ray Jones. The focus of this study was to design a

‘chassis’ suitable to allow a carer or staff member in a caresetting to take a video-call and wheel it around to a residentor patient. The older person, perhaps with cognitive declineor dementia, may see it as a telephone call but where you cansee the other person on a screen (an IPad or tablet). ThisSoW device was first introduced into a care home in DevonUK in 2014, where two residents successfully began to useSkype to communicate with family. However, for those withmore advanced dementia it was felt, as a minimum, residentsneeded to be able to engage with and understand televisionin order to successfully use Skype. This early proof ofconcept study suggests that video-calls are likely feasiblewith older adults with no noticeable or mild cognitiveimpairment and perhaps early onset or moderate dementiarather than severe.

Collaboration with care home staff, family and residents iskey to ensuring that an intervention such as video-calls couldbe feasible in aiding older people to stay in touch withrelatives within a care setting. Therefore, the team atPlymouth University have begun to collaborate with olderpeople, with or without cognitive decline, living in care homesacross Devon, along with their families and staff members, toassess feasibility and acceptability through a pilot trial. Inaddition, outcome measures of loneliness, social networksand well-being will be assessed through qualitative andquantitative measures. This pilot trial will enforce a futuredefinitive trial that can be implemented across all care homesin the UK.

ReferencesDickens, A. P., Richards, S.H., Greaves, C.J., Campbell, J.L. (2011). Interventionstargeting social isolation in older people: a systematic review, Bmc Public Health, 11.Deci, E.L., Ryan, R.M. (2008). Self-Determination Theory: A Macrotheory of HumanMotivation, Development, and Health. Canadian Psychology-Psychologie Canadienne, 49,pp.182-185.Masi, C.M., Chen, H.Y., Hawkley, L.C., Cacioppo, J.T. (2011). A Meta-Analysis ofInterventions to Reduce Loneliness. Personality and Social Psychology Review, 15,pp.219-266.Jimison, H.B., Klein, K.A., Marcoe, J.L.,(2013). A socialization intervention in remotehealth coaching for older adults in the home, Conf Proc IEEE Eng Med Biol Soc, 7025-8.Choi, N. G., Marti, C. N., Bruce, M. L., Hegel, M. T., Wilson, N. L., Kunik, M. E. (2014).Six-month postintervention depression and disability outcomes of in-home telehealthproblem-solving therapy for depressed, low-income homebound older adults. DepressAnxiety, 31(8), pp.653-661.Tiberio, L., Cesta, A., Olivetti Belardinelli, M. (2013). Psychophysiological Methods toEvaluate User’s Response in Human Robot Interaction: A Review and Feasibility Study.Robotics, 2, pp.92-121.Golden, J., Conroy, R. M., Lawlor, B. A. (2009). Social support network structure in olderpeople: Underlying dimensions and association with psychological and physical health.Psychology Health & Medicine, 14, pp.280-290.Bamford, C., Bruce, E., (2000). Defining the outcomes of community care: theperspectives of older people with dementia and their carers. Ageing and Society, 20,pp.543-570.

Sonam Zamir PHD student

Plymouth University

autumn 2016 issue fifteen innov-age magazine 21

Dr Matthew PrinaLecturer in Ageing and Mental Health

Institute of Psychiatry, Psychology andNeuroscience, King’s College London

Depression and healthy ageing:current state of the evidenceMatthew Prina is an Epidemiologist and Lecturer in Ageing and Mental Health at the Institute ofPsychiatry, Psychology and Neuroscience, King’s College London (KCL). His research interests includeageing, mental health, frailty and the co-morbidity between mental disorders and other non-communicable diseases. He is author of several articles on mental health in older age and co-author ofthe Dementia UK report and of a number of recent World Alzheimer Reports. He currently leads,together with Professor Martin Prince, the KCL team of the ATHLOS project (Ageing Trajectories ofHealth: Longitudinal Opportunities and Synergies).

A better understanding of how we age will provide insightinto interventions that can alter pathways to old age,promoting healthy ageing, and subsequently having apositive impact in our ageing societies. Although there issome evidence on the beneficial effect of altering ageingtrajectories upon population health (Depp et al.), we still donot fully understand what drives pathways to healthyageing. ATHLOS (Ageing Trajectories of Health:Longitudinal Opportunities and Synergies) is an EU-fundedproject bringing together 14 partners from 11 EuropeanCountries which aims to achieve a better understanding ofageing through the identification of healthy ageingtrajectories, determinants of these patterns, critical pointsin time when changes in trajectories occur, and timelyclinical and public health interventions to optimise healthyageing (more information is available at:http://athlosproject.eu/).

As part of this project, Dr Carolina Kralj (ATHLOS team,KCL), has systematically assessed the evidencesurrounding biological, behavioural, psychological andsocio-demographic determinants of healthy ageing acrossthe life span. One of the most consistent factors predictinghealthy ageing was found to be depression.

Nine studies were identified which explored the longitudinalassociation between depression and healthy ageing,comprising a total of almost 50,000 participants. Thefindings across the studies, which were of relatively goodquality and primarily carried out among people living in theUSA, were consistent. Seven out of nine studies reportedthat having depression at baseline was associated withreduced healthy ageing at follow-up.

It is already known that depression is a primary cause ofdisability (Ferrari et al.), reduced quality of life (Sivertsen etal.), hospitalisation (Prina et al.), and mortality (Cuijpers etal.) across the life-course, but it seems likely thatdepression also has a role in whether we age successfully.Given that psychological and pharmaceutical treatments fordepression are readily available and have demonstratedreasonable effectiveness, our finding leaves the door open

to future intervention studies which could potentiallyevaluate whether targeting depressive symptomatologycould shape healthy ageing.

It is important to highlight however, that depression is likelyto be a smaller piece of a larger puzzle, where many factors(biological, behavioural, psychological, environmental andsocio-demographic) interact to produce the overallobserved effect. Using a large harmonised data set,including over 20 international longitudinal studiescomprising more than 340,000 individuals, the ATHLOSproject will explore how these complex interactions shapehealthy ageing trajectories over time. This deeperunderstanding of ageing will also result in the creation of amore realistic definition of “old age”, beyond the standardchronological approach.

ReferencesFerrari, AJ., Charlson, FJ., Norman, RE., Patten, SB., Freedman, G., Murray, CJL., Vos,T., Whiteford, HA. (2013). Burden of Depressive Disorders by Country, Sex, Age, andYear: Findings from the Global Burden of Disease Study 2010. PLoS Medicine, 10(11),e1001547.Cosco, TD., Prina, AM., Perales, J., Stephan, BCM., Brayne, C. (2014). Operationaldefinitions of successful aging: a systematic review. International Psychogeriatric, 26,pp.373–381.Cuijpers, P., Smit, F. (2002). Excess mortality in depression: a meta-analysis of communitystudies. Journal of Affective Disorders, 72, pp.227–236.Depp, CA., Harmell, AL., Jeste, D. (2014). Strategies for successful aging: a researchupdate. Current Psychiatry Reports, 16(10), p.476.Prina, AM., Cosco, TD., Dening, T., Beekman, A., Brayne, C., Huisman, M. (2015). Theassociation between depressive symptoms in the community, non-psychiatric hospitaladmission and hospital outcomes: a systematic review. Journal of PsychosomaticResearch, 8(1), pp.25-30.Sivertsen, H., Bjørkløf, GH., Engedal, K., Selbæk, G., Helvik, AS. (2015). Depression andQuality of Life in Older Persons: A Review. Dementia and Geriatric Cognitive Disorders,40(5-6), pp.311-39.

Acknowledgement

This project has received funding from the European Union’s Horizon 2020 research andinnovation programme under grant agreement No 635316.

What is healthy ageing?Although many different terms have been used to describehealthy ageing (e.g. successful, productive, active, positive,etc.), a consensus on its conceptual and operationaldefinition has not yet been reached (Cosco et al., 2014). It is, however, accepted that healthy ageing cannot onlyrepresent the lack of disease, but also a longer life with lessdisability, as well as high levels of physical and mentalfunctioning with active engagement.

innov-age magazine issue fifteen autumn 201622

Article

PaperWeight Armband Kirstine Farrer, Consultant Dietitian at Salford Royal NHS Foundation Trust, is leading the team thatis pioneering the PaperWeight Armband – a non-medical, non-intrusive tool that is helping healthand social care professionals identify older people at risk of malnutrition and signpost them toinformation and advice. Now, thanks to a partnership with Age UK Salford, the PaperWeightArmband is available across the country to help save lives and cut costs associated with treatingmalnutrition – all with a simple strip of paper.

There has never been a more urgent need for health careproviders and commissioners to act and address theproblem of malnutrition in older people. Needlesssuffering, neglect and inconsistent standards of dignityare unacceptable. Malnutrition is a major cause andconsequence of poor health and older people areparticularly vulnerable. Not only is this intolerable from ahealth perspective for the quality of life in older people,malnutrition can lead to more hospital admissions andre-admissions, longer hospital stays and greaterhealthcare needs. Consequently, the cost of malnutritionhas spiralled out of control with BAPEN (the BritishAssociation for Parenteral and Enteral Nutrition)suggesting this may be around £19.6 billion each year(Elia, 2015). One in 10 older people, equating to aroundone million older people in the UK, are suffering from orare at risk of malnutrition. Furthermore, more than one infour are malnourished or at risk of malnourishment onadmission to hospital.

Mid-arm musclecircumference is a well-established surrogatemeasure for body massindex. The PaperWeightArmband is, as its nameimplies, a paperarmband that can beused to measure armcircumference. If thePaperWeight Armbandcan be stuck together atthe red line and slide

freely up and down the upper arm, clearly the armcircumference is less than 23.5cm. This may suggestthat the person has a body mass index of less than20kg/m², an indication of being underweight and at riskof malnutrition. By having a QR code on the armband,the carer can immediately get access to a high energyprotein diet sheet written by community of dietitians andolder adult residents in Salford. This leaflet includesfurther information, advice and support available locally,such as food banks and Age UK Salford services. Theguidance outlined in the leaflet should be followed for amaximum of 12 weeks, following which time if there is noimprovement, the advice is to ask to see a health care

professional. Data from the Salford Public Health teamhas shown a decrease in hospital related admissions formalnutrition in the last year. Case studies alsodemonstrate an increase in the proportion of olderpeople who feel supported to manage their ownconditions, thus improving the quality of life for serviceusers and carers.

The Salford Age UK volunteers and community assetgroup found the PaperWeight Armband easy to use. Onevolunteer said, ‘it has allowed us an opportunity tobroach the subject of malnutrition; It saves us time aswe don’t need to refer to GP to then refer on to thedietitians, but we have the safety net of working closelywith the community and hospital dietetic teams when wereally need their advice. I don’t see any reason why wecan’t incorporate this into our Age UK Salford hospitaldischarge work programme’.

Due to the positive feedback from colleagues around theUK, Age UK Salford have now partnered with SalfordRoyal NHS Foundation Trust to upscale and spread thePaperWeight Armband. Mr Dave Haynes, ChiefExecutive from Age UK Salford, accepted a public healthexcellence award at the House of Commons in June onbehalf of the team from Salford.

The PaperWeight Armbands can be purchasedby health care providers. For more informationon the PaperWeight Armband, please visit thefollowing link: http://www.ageuk.org.uk/salford or follow us on Twitter -@PArmband.

Dave Haynescollecting the awardfor the Paperweight

Armband

Kirstine FarrerConsultant Dietitian

Salford Royal NHS Foundation Trust

References

Elia, M. (2015). The cost of malnutrition in England and potential cost savings fromnutritional interventions. [online] Available at: http://www.bapen.org.uk/ [Accessed 15Aug. 2016].

autumn 2016 issue fifteen innov-age magazine 23

Kate Bennett

What is your current positionand what was your career paththat took you there?I am a physiotherapist specialising infalls and balance issues in the elderly,working in the community ofSouthampton. I fell into this area ofwork (pardon the pun) after attending acourse with a friend on dizziness andbalance in the elderly several years ago.I have worked with the elderlypopulation for a number of years in avariety of settings including hospitals, inthe community and in clinics. I have alsoworked as a project manager both in theNHS and for the Chartered Society ofPhysiotherapy (CSP) where I worked ontheir ‘Physiotherapy Works’programme.

What challenges do you face in your current positionand which has been thegreatest one?The greatest challenge is the lack ofintegration between health and socialcare. For example, when people comeout of hospital we need to ensure alltheir needs are met in the community.This lack of integration leads toimmense problems with the setting upof appropriate care packages. Thisleads to longer stays in hospital andalso a higher risk of people beingreadmitted because they cannot cope athome.

In your opinion, what are the topthree issues affecting the careof older people?• Increase in an ageing population –

we are not prepared for this

• Lack of co-ordination of health andsocial care nationally

• Lack of options for elderly patientswho don’t need to be in acutehospital beds – we need more stepup/step down facilities to enablepeople to recover theirindependence in appropriateenvironments

What advice would you give tosomeone contemplating followingin your footsteps?Be brave, think outside the box anddon’t be afraid to bend the rules (withinreason) and argue your case. Also workout who your allies are and talk to them.I knew I needed to get A&E onside andconsider how they worked before Icould set up the pathway so I went andworked with them in my own time andat all hours of the day.

Where do you go for advice and information?I have a number of mentors for variousthings so I usually consult them… orGoogle!

Who would you most like to workwith?Simon Stevens (Chief Executive of NHSEngland)…I have a few ideas to share!

What do you enjoy doing when youare not working?The aforementioned five horses tend totake up most of my time. Other thanthat I love sewing, reading and watchingany sport except football. Occasionally Iget to see my husband too!

What do you do in a typical working day?There is no such thing but it generallyinvolves treating patients and drivingaround Southampton plus the oddmeeting.

If you were stranded on adesert islandwhat wouldbe your oneluxury?My mobilephone because I can literally doanything on it. I would justhope they haveWi-Fi…

What changes in elderly care doyou anticipate in the next fewyears?I anticipate that more and more serviceswill be community based and thatprimary care will have a greater role inthe care of our elderly population. Ihope that in five or ten years’ time A&Ewill not be the default setting for theunwell elderly but they will have accessto more intermediate care facilities orcommunity-based services. I also thinkthat society as a whole will becomemore dementia friendly with the growingprevalence of this disease.

If you hadn't become aphysiotherapist, what might youhave done?My passion outside of work is horses (I currently have 5) so I like to think Iwould have been on the Olympic threeday event team!

What experience has influencedyour career the most?It was the day I was inspired to set upmy pathway for elderly patients toaccess rehabilitation services directlyfrom A&E. A patient from a residentialhome had come in via A&E with a brokenpelvis and had ended up on the acutewards. She had severe dementia andkept refusing her painkillers;subsequently she was refusing to walkbecause of the pain. When she camedown to the rehab ward where weworked, we found ways of encouragingher to take her medicine and shegradually was able to use an aid to standand move around with. Sadly she neverregained enough mobility to return toher residential home and had to move toa nursing home. The saddest thing wasshe lived in the residential home with herbest friend; they had been to schooltogether. We felt that if she had hadaccess to specialist elderly rehabilitationearlier, we may have been able to gether back to her friend. At this point Istarted thinking there must be a betterway… The pathway I set up won awardsand was presented internationally. It alsoprompted my move into projectmanagement which enabled me to takeon a more strategic role with the CSP.

Project Manager on the Physiotherapy Worksprogramme for the Chartered Society of Physiotherapy

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In our next quarterly issue ofInnov-age we will be looking atOlder People and Cancer.

Half of all cancer cases in the UK each yearare diagnosed in people aged 70 and over(Cancer Research, 2011-2013). With 1 in 2people now diagnosed with some form ofcancer during their lifetime, it is an extremelytopical and important healthcare issue todiscuss.

Join us for the next issue of Innov-age whereour contributors share their knowledge andexperiences of cancer care and otherimportant eldercare issues…